Please rate the impact of your communication problem on the following areas of your life:
| Area | No impact (normal) | Very little impact | Some impact | Significant impact | Profound (cannot perform in this area) |
| Professional (how well are you able to perform your job duties?) | |||||
| Social (Do you do the things you used to do for enjoyment with friends and family?) | |||||
| Communicative (Are you able to understand what people say, and can others understand you?) | |||||
| Physical (Do you feel tired or ill?) | |||||
| Emotional (Do you feel strong emotions --sadness, anger, frustration -- because of your impairments?) |
How important is to you that your communication problem be resolved or lessened?